Fifth Year Update - Beginning to Feel Useful
And just like that, my final medical exams, ever, are over. It’s pretty incredible. The end of fifth year is dreamt about from the very first days of JCU medicine as
the ultimate exhilarating moment of medical school at JCU, perhaps moreso than actually graduating at the end of sixth year. A catharsis like no other after five continuous years of gruelling study before embarking on the “mini-internship” of sixth year before you actually graduate as a doctor. Yet, finishing, oddly, wasn’t the transcendental experience advertised; it just felt like another day, another sigh as I realised this was only the beginning of a new chapter in the never ending cogwheel of Medicine. But if we look past the cynicism, it does feel good, even if the moment is fleeting, to be able to appreciate that the worst is over, for now, and I don’t have to feel guilty about relaxing and doing, well, nothing, for a few weeks before sixth year commences. To spend time with family and read for leisure again.
Overall, I’ve enjoyed this year. For those keen followers of my MSO blog posts, if any exist, you might recall last year I was rather unapologetic in my criticism of the course structure and teaching. In particular, I whinged about the frivolousness of allocating us to wards with no guidance or teaching, yet chastising us when we sought opportunities to leave early to do our own study. Thankfully, placement this year was far better (probably because we were allocated into actual medical teams) and I honestly felt we started to feel like we were becoming more useful and relevant.
As I commence my penultimate review of the JCU medical course, please note once again that my perspective is unique only to that of Townsville, so once again, the experiences of my fellow Cairns and Mackay colleagues are likely to differ significantly.
Course Structure
Fifth year commences early in the second week of January and once again the structure is completely different from previous years. The general overview of the year is you will rotate through 3x 12 week blocks, each with 2x 6-week modules in various medical specialty fields (described in more detail below). Each 12 week block is preceded by a 1 week “Base Week” generally delivered over Zoom from Townsville to the Mackay and Cairns clinical sites to dump as much lecture content as possible for the 2x modules to come. You get a 2-week lecture recess at the end of the first 12 week block, and a similar 2-week recess at the end of the second 12 week block. But that’s it for “holidays” this year. If you want,
here’s the actual 2023 JCU MBBS timetable for reference.
Everyone rotates through the modules differently, and depending on your clinical site, you will have between 4-12 people in the same rotation as you who will be the people you spend the most time with on placement all year. You’ll find you probably won’t see anyone who’s in a different 12 week block outside of the base weeks, and indeed some people in your year you may not even notice at all until exams at the end of the year, given the unique way 5th year runs!
The general overview can be laid out by the following:
- Block 1
- Mental Health (MH) - 6 weeks
- General Practice (GP) - 6 weeks
- Block 2
- Adult Health 1 (AH1) - 6 weeks
- Adult Health 2 (AH2) - 6 weeks
- Block 3
- Child and Adolescent Health (CAH) - 6 weeks
- Reproductive and Neonatal Health (RNH) - 6 weeks
As mentioned, the exact order you will go through these modules throughout the year will be extremely variable depending on your rotation. But you will always do the same rotation modules within each 12-week block (i.e. you will never do MH followed by AH1; it will always be with GP).
With the exception of students who opted at the end of last year to spend 1 or 2 of their 12 week blocks in Mt. Isa as a special placement opportunity, there is no rural in 5th year. As I didn’t go to Mt. Isa, I can’t comment personally on the experience, however I do have a few friends who went who tell me they had a fantastic time.
Subjects/Rotations Overview
The subjects in fifth year really cover the “essentials” of clinical Medicine, with the more “niche” specialities reserved for 6th year rotations.
Mental Health (MH)
This is probably the most “different” specialty of the year, as you can imagine. You get thrust into Psychiatry and will rotate through both inpatient placements at the mental health unit (MHU), CL-psych, and community placements such as with ATODS, CYMHS, Forensic Psychiatry or ACT. At least in Townsville, not everyone got the same exact placements, aside from a week at the inpatient MHU. Overall I really enjoyed this placement, and I think you’ll find even students who have absolutely 0 interest in pursuing psychiatry as a specialty later on actually admit feeling like it was a really valuable experience to be able to see such a unique aspect of Medicine. Indeed, the first time you meet an acutely psychotic or suicidal patient in the high dependency unit is not something you can easily forget. There are so many memories I have, all of which make me ever more appreciate the role of psychiatrists, who deal with such a complicated array of conditions which essentially the rest of clinical medicine refuses to touch. Yet psychiatrists still deal with, on occasion, a residual contempt by the rest of the profession for not being “real doctors”, which is disappointing.
It also made me realise that even if you absolutely cannot think of anything worse than spending all your time with patients suffering from mental illnesses, you cannot escape dealing with them, whatever specialty path you take. The number of times I saw the on-call Psychiatric registrar get calls from various junior RMOs and even medical registrars about “aggressive” or “depressed” patients expecting them to wave their magic wand and cure them of their normal human emotions was astounding. In one case that I remember distinctly, a 60 year old patient had just undergone a bowel resection with stoma insertion and was recovering on the surgical ward. The doctor overseeing their care had called the ACT team for an assessment because they had become withdrawn and “emotionally unstable” and “wouldn’t answer their questions” post-operatively. Of course they’re going to be upset; they’ve just had surgery for cancer, and will no longer experience the same sort of continence the majority of the population have! It seems to me problematic, and indeed this is what the psychiatrists I was with expressed, if general medical doctors cannot deal with acute, normal, expressions of grief and emotion in a hospital setting, and feel the need to outsource “treatment” of these emotions to Psychiatrists as if it’s their job to some how console these patients. I think this was one of the biggest learnings we all had – that we need to stop pathologising emotions; if we’re in hospital chances are we are going through something tough. Expecting everyone to be chippy and happy all the time is just not human, and we have to all, as doctors of all specialities, be able and willing to support our patients and their mental health as part of a holistic approach to care. It is not the role of the psychiatrist to be an on-call counsellor or psychologist.
Anyway, rant aside, the focus of these 6 weeks outside of placement is to really
know but not
memorise the DSM-V criteria to the main commonly seen conditions in psychiatry. The learning outcomes we got were pretty vague, so I ended up stopping using them to really guide my study after a few weeks, but in general you should know depression, anxiety, PTSD, bipolar, schizophrenia and the personality disorders inside out. There’s obviously a lot of other conditions, but in general if you’ve seen it on placement somewhere, it’s likely to be highly prevalent in the community, and therefore more likely to be assessed in the exams. There’s always a debate about whether you need to learn the DSM-V criteria exactly for each of the conditions, and indeed some people do learn it all – I think personally it’s an enormous waste of time to be able to recite word-for-word the criteria, when I had such a vast amount of other content to try and memorise. So outside of the main conditions of which I could loosely recall the general criteria (you’ll notice there’s some overlap which helps), I mainly picked up the key features of each so I could at least recognise it if it came up in an MCQ/SA paper, and learnt all the timeframes for each (ie. brief psychotic disorder is evidence of psychotic symptoms for <1 month, schizophreniform disorder is evidence of symptoms for between 1 month to 6 months, schizophrenia is evidence of symptoms for >6 months) as this is a huge distinguishing feature amongst the similar conditions.
There’s also some on-course assessment worth a cumulative total of 5%, such as a oral case presentation, observed clinical encounter and mental health discharge summary. For the sake of brevity, I’m not going to go into the details of these. But as you can imagine, you’re pretty busy over these 6 weeks; juggling 8am-4pm (generally) days of placement, generally 1-2 hours of weekly lectures by different psychiatrists, the on-course assignments and actual course content, which you’re expected to pretty much learn by yourself after hours.
Overall, mental health was great fun! You see some really fascinating patients, and I don’t know how accurate this is, but I’ve found in general psychiatrists tend to be much more caring and protective of medical students. I felt like a valued part of the team, and even got to see some consults with patients by myself after a while.
General Practice (GP)
General Practice is arguably the most “useful” of clinically applicable rotation you have in 5th year, although experiences do differ drastically depending on where you end up. In Townsville, I was allocated to a local general practice where you are the only student there on placement for 6 weeks. You generally are told to rock up for 5x 3-hour blocks over the week, which means you actually have a fair bit of free time, with most people only on placement for 2 and a half days a week. You are also expected to head into to university for one morning a week for teaching and some basic GP clinical skills. Overall, most people agree the GP rotation is the most relaxed and many people like finishing on this rotation, as there is definitely plenty of time to study, and the on-course assessment isn’t too intensive; a few mini-CEX’s and a case write-up.
The biggest benefit of the GP rotation is the doctors generally give you a lot more freedom you aren’t afforded in the hospital setting. In my case I was given my own room and where patients’ consented, I took a basic history of the patient’s presenting complaint before handing over the case to the patient’s actual doctor, outlining briefly my provisional diagnosis, key investigations I would order and brief management plan, if relevant. It’s great for developing communication and clinical reasoning skills, and for being concise with your diagnostic method. What you’ll find in GP is time is a crucial resource and you are forced to be as direct as possible with your questioning otherwise both the patients and your supervising doctors will get annoyed at you for wasting their time. As you would expect, you get a wide variety of exposure to all sorts of Medicine, and perhaps unsurprisingly – a significant number of mental health presentations.
Adult Health 1 (AH1)
Adult Health 1 is basically your internal medicine rotation. In Townsville we got 2 weeks of a specialty rotation (ie. cardiology, nephrology, respiratory medicine, neurology), 2 weeks of general medicine on the ward, and then the remaining time at one of the special acute assessment units where patients are triaged before being allocated onto a certain ward.
All in all, this is basically all of fourth year’s content squeezed into 6 weeks, so it’s pretty intense. The other thing with AH1 is you will do 2x mini-OSCE’s at the end of the rotation, so this is the rotation where everyone is studying Talley & O’Connor’s ‘Clinical Examination’ religiously, as theoretically anything can come up, and in most cases the tutors actually find patients on the ward with clinical signs you’re expected to pick up in the assessment. It’s supposed to be a wake-up call for the AH1 OSCE at the end of the year.
While the ward rounds went on for quite a long time (sometimes the AM ward round wouldn’t finish to 1 or 2pm), it is great learning as a medical student, depending on the team you get. I was lucky I had a reg who would quiz us all, including the intern and RMO, on all facets of clinical medicine, and then get us to present on certain topics later on the week. All was great learning, and for this we were rewarded with our small cappuccino on the consultant’s card every morning.
Adult Health 2 (AH2)
Adult Health 2 is your surgery rotation. Once again you typically get allocated a specialty (ie. vascular, urology) for 3 weeks followed by a general surgery rotation for the remaining time.
Look, I’ll be honest – I never thought I’d like surgery. I kept an open mind, but it just about met my expectation. While I was lucky to have a decent team that for the most part looked after me, I really just did not like standing in the corner in theatre watching (largely) laparoscopic work done on patients, day after day. I’m sure if you’re into surgery, this would make you froth, and I’m sure you would have been offered to scrub in and get involved more often than I did. But I scrubbed in once, and I think that was enough for me. I can see the attraction of 30 minute ward rounds and then straight into theatre though. Clinic was a better experience for me, as I got to chat to patients in the outpatient setting and employ some clinical reasoning, which was much more useful for me as a 5th year than the technical side of surgery.
While I definitely saw one or two arrogant surgeon consultant types that would publicly humiliate registrars and nurses in theatre, I was very happy to see that this was not a common occurrence. There is a stereotype about some of the surgical specialities… but for the most part I felt most surgeons, especially the younger ones were understanding that not everyone loves surgery and if you felt it was better use of your time to go to the library to study, they were happy enough for you to leave, as long as you were respectful and showed up to ward rounds and at least poked your head into theatre every now and then.
In your surgery rotation your experience will very much depend on your team, so I know there is some variability in this regard, however I did overall enjoy the experience of being with a surgical team, even if I know I don’t see myself ever ending up in surgery down the track.
Community and Child Health (CAH)
CAH is Paediatrics in 6 weeks. By far the most well-designed rotation, thanks to the magnificent work of Dr. Sue Gorton! If you’ve ever had the pleasure of being taught by her you’ll no doubt concur with me that she is one of the most loveliest people you’ll ever meet. Truly caring in every way and makes you feel special, always checking up on you to make sure you’re doing okay academically but also on placement. As a result of it being very meticulously planned out, this is the rotation where you are likely to be really short for time as you’ll be either on placement or in lectures pretty much 8-5 most days, so bare that in mind if you have CAH/RNH later in the year. While Dr. Gorton’s expectations are high, you will learn a lot, probably because you really just don’t want to disappoint Dr. Gorton who very clearly wants you to succeed.
You will rotate through all sorts of paediatric medicine, from paediatric ward rounds, community clinics (including CYHMS), baby checks, a week in PICU and paediatric surgery. You’ll spend most of your time with paediatricians, but also see the interplay between other specialities and allied health. In general, learning will follow guidelines outlined by Royal Children’s Hospital (RCH) Melbourne and the Paediatrics at a Glance Textbook. You’ll focus on the conditions which are most frequently seen, so bronchiolitis, pre-school wheeze, asthma, and so on. There’s also a focus on some mental health conditions including ADHD and eating disorders, as you’ll inevitably see this in paeds as well.
Overall most people really enjoy CAH in Townsville, largely thanks to Dr. Sue’s tireless work throughout the year and making sure every rotation gets supported as much as possible.
Reproductive and Neonatal Health (RNH)
Finally – RNH is your obstetrics-gynaecology rotation. Some people love it, some people hate it. I fell somewhere in the middle. You get rotated through birth suite, gynae clinics, theatres, and so on. Unfortunately in Townsville, this rotation was by far the most poorly organised, and it felt very chaotic at times. I think seeing a vaginal birth for the first time is an incredible experience, but unfortunately you only have a limited time to "see" your baby and get your sheet with a list of things to see "signed off", and this means instead of enjoying the experience you're constantly anxious about making sure the consultant signs your piece of paper. This became increasingly difficult when consultants were barely seen, or due to the fact that turnover of clinicians was so commonplace, and therefore it was hard to get signatures to "prove" you attended. Anyway, this rotation you will spend a lot of time reviewing QLD clinical guidelines for things like PPROM, Termination of Pregnancy, etc. and for those that love Women's Health, it will be a really exciting experience. I was lucky to have a great NICU team and learnt a lot here. But unfortunately my birth suite experience was not great - a lot of the midwives, nurses and even the doctors clearly did not want me there. I hear it's difficult as a male student, and even more difficult if there's not a whole lot of births happening, as you're the bottom of the food chain when it comes to possibly sitting in on the birth. But oh well. Probably my least favourite rotation, but I think this was less about the content, but more about the structure and honestly the culture within the specialty. I didn't like how some of the doctors treated their nurses and midwives, nor did I like how some of the midwives felt so territorial, even towards the medical students. I was lucky to not have this experience, but I had to really try to be overly nice and respectful to everyone as to not step on anyone's toes. I didn't really have the same experience in any other rotation.
Assessment
Aside from the on-course assessment which I’ve outlined briefly in the modules above, your final exams in mid-November comprise the bulk of your overall assessment for the year. The loose breakdown is as follows:
- On course assessment: 30% (6x5% per module)
- Key Feature (Written) Paper (KFP): 23.3%
- MCQ: 23.3%
- OSCE: 23.3%
Overall this year it’s increasingly difficult to “predict” what’s going to come up. If I’m being honest, in previous years if you study past papers with a fine tooth comb and tailor your study accordingly, you will generally catch on to what JCU generally assesses and you will generally perform pretty well. In fifth year, after sitting the exams, past papers tended to be less relevant, and anything really is fair game. In a way, this is good because it prevents students from narrowing the focus of their study solely to what has been previously assessed, however many do feel overwhelmed because you feel like you’re always playing a game of “how much do I really need to know” throughout the entire year. Especially when every single clinician and lecturer will say a different thing as to what you “need to know”. Ultimately there’s no real way to game the system – you will all end up studying differently and cover different content, but at the end of the day the vast majority of us pass; so anything more is purely for self-gratification and better preparing your knowledge base for internship. After a few months, I ended up just studying less for exams and more for my own interest. Yes, there is content I went into far too much detail that there’s no way they would possibly assess it, and perhaps at the sacrifice of other content, but I preferred the freedom to study what I wanted in a weird way.
In terms of specific exams, it’s been a while now so I’m relying on my very hazy memory, however I remember the KFP being pretty fair. Questions are generally straightforward enough, with multiple “correct answers” to choose from. Sometimes there’ll be a long case to read, but most of the time the details in it aren’t actually that relevant to what you can put down as the answer. Aside from the time pressure, which is pretty brutal, the most difficult thing about the KFP is it feels like you’re playing a game of “Family Feud” because even though you may have a technically correct answer to a question, if most other students put down a different answer that is equally correct, you’re better off opting for that answer instead, because the marks are generally allocated based on the most common answer to the question (which if most people’s answers contradict their written answer; they’ll change it as they’ll assume the question was worded poorly). Unfortunately you can’t argue your case for a niche correct answer when you have no involvement in the marking process. It’s partly why I really dislike we still have a written exam component to assessment; the subjectivity of it all is just so frustrating. I can understand why other medical schools, including UQ as far as I’m aware, don’t have any written exam component to their final exams. I sat the exam on little sleep, as has become typical for me, so made a few silly mistakes along the way including just straight up misreading a few questions. But that’s life.
The MCQ is where I personally thrived; because it’s an objective assessment of knowledge. You either know the correct answer or you don’t. Having done a lot of past MCQs, mainly PassMed, I felt pretty prepared and overall felt very good walking out of it, even if there were a few gnarly questions in there which were definitely semi-educated guesses. The MCQ exam is generally where they reserve the “hard” questions for, so this was to be expected. I’m lucky I reviewed statistics, because there were quite a few questions on this, and that helped me secure a few extra marks that I know a lot of other people didn’t even bother attempting.
In terms of how I studied, there's no one "right way", but I did rely a lot on Anki as a memory aid. I have been a lead contributor on the "Malleus Clinical Medicine" project with a number of senior medical students from around Australia - I used this a lot throughout the year. If you're interested, feel free to check out the details here:
Making a Dedicated Australian Preclinical/Clinical Medicine Anki Deck using AnkiHub - Callout for Volunteers. It's no where near complete, but it's a start, and we're slowly progressing into creating a great resource for students preparing for internship. I also did PassMed for MCQs and keeping me constantly tested on various clinical med concepts, listened to ZeroToFinals podcasts whenever I had a spare minute or when I went on walks/runs, and AMBOSS was great for filling in the gaps everywhere else. eTG was good for Australian-specific management protocols, and UpToDate for more general international approaches. I just didn't really have time to seriously study textbooks this year outside of Talley & O'Connor, and I think this was a shared experience. This approach got me through with some of my best marks so far in the course, but I'm not saying it was the "ideal" way to study, nor was it by any means the most ordered.
Final Thoughts
Fifth year is a big year. You will increasingly spend your “free” time studying, because you really don’t know what’s going to come up on the final exams. But you come out feeling the most clinically competent and at least somewhat "ready" to start work. In many ways, 6th year is annoying because many 6th years will tell you the lack of stress means you will forget a lot of the stuff you learnt in 5th year before you commence internship. Once again, the skills of ascertaining the depth to learn content are essential. It’s stressful so having a good support base of friends is even more important, because it can be very easy to feel lonely this year. I had a lot of family stuff going on which was difficult to navigate, but still managed to get through in the end. Finding good study groups, if that’s how you like studying, can be good to keep you both motivated and identify weakness areas. But it shouldn’t be all study – I managed to keep involved with some extra-curricular pursuits including a new weekly sport. As cliché as it is, balance really is key. I had friends who kept with part-time jobs and still passed fine, so I would say you shouldn’t necessarily to listen to the person who says you have to sacrifice everything. In fact, I would argue this is the wrong approach to take, and you will almost certainly burn out before exams if you do so.
In terms of big criticisms of the year, there’s a lot to mention, but unlike last year, I guess a lot of them aren’t necessarily unique to JCU or can easily be changed. For example, something that really irritated us was the number of lectures that would be cancelled minutes before they were scheduled by clinicians, especially in the RNH rotation. I know clinicians are busy, but it definitely made us feel disrespected making us come all the way into uni on many occasions, just to be told “you can go home now”. Let alone the fact that we didn’t get our on-course assessment marks for most of our rotations back for literally 6 months after we submitted them. Our final base week was also meant to be a review week, but was loaded with new content by specialities including a 2 hour lecture by a cardiologist about the latest European guidelines for management of myocardial infarctions… which frustrated us all as we sat there sacrificing our precious time as we realised this was somewhat useless for us at this stage. I think placement in many rotations was a bit useless, especially when the doctors didn’t care much for you or didn’t want to teach. That being said, in general it was far better than 4th year. I think the persistent fear campaign of attendance and getting signatures each week made us feel like children which I think is unnecessary. I believe at this stage the uni should trust us to attend, and leave if we’re not learning anything to go home and study. Obviously if you don’t show up at all, that’s another story, but I think the supervising doctors at that stage would be able to pass that onto the uni. I also wish there was a bit more consistency in terms of quality lectures/lecturers – the amount of variability in quality across sites and within each rotation is astounding. Hopefully some changes can be made moving forward, but given JCU sacked a lot of academic services staff at the end of last year, the consequences became clear this year. Hopefully another year of getting used to the changes will lead to some improvements.
This might be my final big “blog” post in a while so hopefully it gives any future JCU students a bit of a perspective.
I hope you are all enjoying the final hours of 2023. I’m looking forward to a much nicer change of pace in 2024 as I approach graduation.
reference: I went to Prossie and my partner went to Mosman
